Failure to Administer Medications Within Required Time Frame Due to Staffing Shortages
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for two of three residents reviewed. Specifically, the Charge Nurse did not administer multiple prescribed medications to two residents within the required one-hour window before or after the scheduled medication times. This included medications such as ascorbic acid, carvedilol, prostat, calcium acetate, and robaxin for one resident, and ciprofloxacin and gabapentin for another. The late administration was confirmed through observation, record review, and interviews with staff. The residents involved had complex medical histories, including conditions such as osteomyelitis, morbid obesity, chronic respiratory failure, end stage renal disease, hypertension, pain, acute heart failure, COPD, depression, and neuropathy. The medication administration records and physician orders indicated specific times for medication administration, which were not adhered to on the morning in question. The Charge Nurse acknowledged that the medications were administered late, as indicated by the red color coding in the electronic medication administration system, and attributed the delay to being short-staffed and having a higher resident load than usual. Interviews with the Charge Nurse, Assistant Director of Nursing, Director of Nursing, and Administrator revealed that the late medication administration was not standard practice and that the facility was experiencing staffing shortages at the time. The staff confirmed that the protocol required medications to be administered within one hour of the scheduled time, and that the delay was due to increased workload and lack of timely communication regarding the need for assistance. The facility's policy on medication administration emphasized adherence to the five rights of medication, including the right time, to maximize therapeutic effectiveness.